Registration
Need a little break from the busy life of parenting/care-taking? Bring your kiddo(s) ages 3 and up to the Wellspring Dance Academy and get a little down time! We have a full evening of activities planned including movement activities like obstacle courses and creative movement-style explorations, crafts, snacks, and more. We will keep them busy while you do whatever it is you want/need! Be sure to tell your friends too!
Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Name
First Name:* Last Name: *
Type
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact Info
(Not Contact #1 or #2)
 
 
Students entered below will be added to your family's account
 
Questions/Options:
Does your child(ren) have any medical concerns that we should be aware of? Please describe.
Does your child(ren) have any dietary restrictions we should be aware of? Please describe.
How did you find out about this event?
 
Additional Information:
 
Release of Liability
I confirm my understanding that participation in dance-related movement activities carries with it a reasonable assumption of risk. Wellspring/Cori Terry & Dancers and its instructors are not liable for personal injuries.
I've read the above and agree.
 
Photo/Video Release
I grant permission to Wellspring/Cori Terry & Dancers to use performance and in-class photos and video images of my child for promotional purposes. This helps Wellspring create meaningful, authentic promotional pieces.
I've read the above and agree.
 
Enter your Full Name: *   
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number:  
Name as it appears on card:
Nickname:
Card Expiration Month:   Exp Year:
Address Line 1: Address Line 2:
City: State: Zip: